WO2007139949A2 - Implants vertébraux spécifiques à un patient et systèmes et procédés associés - Google Patents

Implants vertébraux spécifiques à un patient et systèmes et procédés associés Download PDF

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Publication number
WO2007139949A2
WO2007139949A2 PCT/US2007/012517 US2007012517W WO2007139949A2 WO 2007139949 A2 WO2007139949 A2 WO 2007139949A2 US 2007012517 W US2007012517 W US 2007012517W WO 2007139949 A2 WO2007139949 A2 WO 2007139949A2
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WO
WIPO (PCT)
Prior art keywords
implant
patient
model
disc
spinal
Prior art date
Application number
PCT/US2007/012517
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English (en)
Other versions
WO2007139949A3 (fr
Inventor
Randal Betz
Guilhem Denoziere
Original Assignee
Spinemedica Corporation
Priority date (The priority date is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the date listed.)
Filing date
Publication date
Application filed by Spinemedica Corporation filed Critical Spinemedica Corporation
Priority to EP07809193A priority Critical patent/EP2029059A2/fr
Publication of WO2007139949A2 publication Critical patent/WO2007139949A2/fr
Publication of WO2007139949A3 publication Critical patent/WO2007139949A3/fr

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Classifications

    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
    • A61F2/02—Prostheses implantable into the body
    • A61F2/30—Joints
    • A61F2/3094—Designing or manufacturing processes
    • A61F2/30942—Designing or manufacturing processes for designing or making customized prostheses, e.g. using templates, CT or NMR scans, finite-element analysis or CAD-CAM techniques
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
    • A61F2/02—Prostheses implantable into the body
    • A61F2/30—Joints
    • A61F2/44—Joints for the spine, e.g. vertebrae, spinal discs
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
    • A61B17/56—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor
    • A61B17/58—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor for osteosynthesis, e.g. bone plates, screws, setting implements or the like
    • A61B17/68—Internal fixation devices, including fasteners and spinal fixators, even if a part thereof projects from the skin
    • A61B17/70—Spinal positioners or stabilisers ; Bone stabilisers comprising fluid filler in an implant
    • A61B17/7062—Devices acting on, attached to, or simulating the effect of, vertebral processes, vertebral facets or ribs ; Tools for such devices
    • A61B17/7064—Devices acting on, attached to, or simulating the effect of, vertebral facets; Tools therefor
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B34/00—Computer-aided surgery; Manipulators or robots specially adapted for use in surgery
    • A61B34/10—Computer-aided planning, simulation or modelling of surgical operations
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
    • A61F2/0095—Packages or dispensers for prostheses or other implants
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
    • A61F2/02—Prostheses implantable into the body
    • A61F2/30—Joints
    • A61F2/44—Joints for the spine, e.g. vertebrae, spinal discs
    • A61F2/4405—Joints for the spine, e.g. vertebrae, spinal discs for apophyseal or facet joints, i.e. between adjacent spinous or transverse processes
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
    • A61F2/02—Prostheses implantable into the body
    • A61F2/30—Joints
    • A61F2/44—Joints for the spine, e.g. vertebrae, spinal discs
    • A61F2/442—Intervertebral or spinal discs, e.g. resilient
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
    • A61F2/02—Prostheses implantable into the body
    • A61F2/30—Joints
    • A61F2002/30001—Additional features of subject-matter classified in A61F2/28, A61F2/30 and subgroups thereof
    • A61F2002/30003—Material related properties of the prosthesis or of a coating on the prosthesis
    • A61F2002/30004—Material related properties of the prosthesis or of a coating on the prosthesis the prosthesis being made from materials having different values of a given property at different locations within the same prosthesis
    • A61F2002/30014—Material related properties of the prosthesis or of a coating on the prosthesis the prosthesis being made from materials having different values of a given property at different locations within the same prosthesis differing in elasticity, stiffness or compressibility
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
    • A61F2/02—Prostheses implantable into the body
    • A61F2/30—Joints
    • A61F2002/30001—Additional features of subject-matter classified in A61F2/28, A61F2/30 and subgroups thereof
    • A61F2002/30316—The prosthesis having different structural features at different locations within the same prosthesis; Connections between prosthetic parts; Special structural features of bone or joint prostheses not otherwise provided for
    • A61F2002/30535—Special structural features of bone or joint prostheses not otherwise provided for
    • A61F2002/30604—Special structural features of bone or joint prostheses not otherwise provided for modular
    • A61F2002/30616—Sets comprising a plurality of prosthetic parts of different sizes or orientations
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
    • A61F2/02—Prostheses implantable into the body
    • A61F2/30—Joints
    • A61F2/30767—Special external or bone-contacting surface, e.g. coating for improving bone ingrowth
    • A61F2/30771—Special external or bone-contacting surface, e.g. coating for improving bone ingrowth applied in original prostheses, e.g. holes or grooves
    • A61F2002/30878—Special external or bone-contacting surface, e.g. coating for improving bone ingrowth applied in original prostheses, e.g. holes or grooves with non-sharp protrusions, for instance contacting the bone for anchoring, e.g. keels, pegs, pins, posts, shanks, stems, struts
    • A61F2002/30884—Fins or wings, e.g. longitudinal wings for preventing rotation within the bone cavity
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
    • A61F2/02—Prostheses implantable into the body
    • A61F2/30—Joints
    • A61F2/3094—Designing or manufacturing processes
    • A61F2/30942—Designing or manufacturing processes for designing or making customized prostheses, e.g. using templates, CT or NMR scans, finite-element analysis or CAD-CAM techniques
    • A61F2002/30943—Designing or manufacturing processes for designing or making customized prostheses, e.g. using templates, CT or NMR scans, finite-element analysis or CAD-CAM techniques using mathematical models
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
    • A61F2/02—Prostheses implantable into the body
    • A61F2/30—Joints
    • A61F2/3094—Designing or manufacturing processes
    • A61F2/30942—Designing or manufacturing processes for designing or making customized prostheses, e.g. using templates, CT or NMR scans, finite-element analysis or CAD-CAM techniques
    • A61F2002/30948—Designing or manufacturing processes for designing or making customized prostheses, e.g. using templates, CT or NMR scans, finite-element analysis or CAD-CAM techniques using computerized tomography, i.e. CT scans
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
    • A61F2/02—Prostheses implantable into the body
    • A61F2/30—Joints
    • A61F2/3094—Designing or manufacturing processes
    • A61F2/30942—Designing or manufacturing processes for designing or making customized prostheses, e.g. using templates, CT or NMR scans, finite-element analysis or CAD-CAM techniques
    • A61F2002/30952—Designing or manufacturing processes for designing or making customized prostheses, e.g. using templates, CT or NMR scans, finite-element analysis or CAD-CAM techniques using CAD-CAM techniques or NC-techniques
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
    • A61F2/02—Prostheses implantable into the body
    • A61F2/30—Joints
    • A61F2/3094—Designing or manufacturing processes
    • A61F2/30942—Designing or manufacturing processes for designing or making customized prostheses, e.g. using templates, CT or NMR scans, finite-element analysis or CAD-CAM techniques
    • A61F2002/30957—Designing or manufacturing processes for designing or making customized prostheses, e.g. using templates, CT or NMR scans, finite-element analysis or CAD-CAM techniques using a positive or a negative model, e.g. moulds
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
    • A61F2/02—Prostheses implantable into the body
    • A61F2/30—Joints
    • A61F2/44—Joints for the spine, e.g. vertebrae, spinal discs
    • A61F2/442—Intervertebral or spinal discs, e.g. resilient
    • A61F2002/4435—Support means or repair of the natural disc wall, i.e. annulus, e.g. using plates, membranes or meshes
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
    • A61F2/02—Prostheses implantable into the body
    • A61F2/30—Joints
    • A61F2/44—Joints for the spine, e.g. vertebrae, spinal discs
    • A61F2/442—Intervertebral or spinal discs, e.g. resilient
    • A61F2002/444—Intervertebral or spinal discs, e.g. resilient for replacing the nucleus pulposus
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2250/00—Special features of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof
    • A61F2250/0014—Special features of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof having different values of a given property or geometrical feature, e.g. mechanical property or material property, at different locations within the same prosthesis
    • A61F2250/0018—Special features of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof having different values of a given property or geometrical feature, e.g. mechanical property or material property, at different locations within the same prosthesis differing in elasticity, stiffness or compressibility
    • B—PERFORMING OPERATIONS; TRANSPORTING
    • B33—ADDITIVE MANUFACTURING TECHNOLOGY
    • B33Y—ADDITIVE MANUFACTURING, i.e. MANUFACTURING OF THREE-DIMENSIONAL [3-D] OBJECTS BY ADDITIVE DEPOSITION, ADDITIVE AGGLOMERATION OR ADDITIVE LAYERING, e.g. BY 3-D PRINTING, STEREOLITHOGRAPHY OR SELECTIVE LASER SINTERING
    • B33Y80/00—Products made by additive manufacturing

Definitions

  • the invention relates to implants, and may be particularly relevant to spinal implants.
  • the vertebrate spine is made of bony structures called vertebral bodies that are separated by relatively soft tissue structures called intervertebral discs.
  • the intervertebral disc is commonly referred to as a spinal disc.
  • the spinal disc primarily serves as a mechanical cushion between the vertebral bones, permitting controlled motions between vertebral segments of the axial skeleton.
  • the disc acts as a joint and allows physiologic degrees of flexion, extension, lateral bending, and axial rotation.
  • the disc must have sufficient flexibility to allow these motions and have sufficient mechanical properties to resist the external forces and torsional moments caused by the vertebral bones.
  • the normal disc is a mixed avascular structure having two vertebral end plates (“end plates”), an annulus fibrosis (“annulus”) and a nucleus pulposus (“nucleus”)- Typically, about 30-50% of the cross sectional area of the disc- corresponds to the nucleus.
  • the end plates are composed of thin cartilage overlying a thin layer of hard, cortical bone that attaches to the spongy cancellous bone of the vertebral body. The end plates act to attach adjacent vertebrae to the disc.
  • the annulus of the disc is a relatively tough, outer fibrous ring. For certain discs, particularly for discs at lower lumbar levels, the annulus can be about 10 to 15 millimeters in height and about 10 to 15 millimeters in thickness, recognizing that cervical discs are smaller.
  • nucleus Inside the annulus is a gel-like nucleus with high water content.
  • the nucleus acts as a liquid to equalize pressures within the annulus, transmitting the compressive force on the disc into tensile force on the fibers of the annulus.
  • the annulus and nucleus support the-spine by flexing with forces produced by the adjacent vertebral bodies during bending, lifting, etc.
  • the compressive load on the disc changes with posture.
  • the compressive load on the third lumbar disc can be, for example, about 200 Newtons (N), which can rise rather dramatically (for example, to about 800 N) when an upright stance is assumed.
  • the noted load values may vary in different medical references, typically by about +/- 100 to 200 N.
  • the compressive load may increase, yet again, for example, to about 1200 N, when the body is bent forward by only 20 degrees.
  • the spinal disc may be displaced or damaged due to trauma or a degenerative process.
  • a disc herniation occurs when the annulus fibers are weakened or torn and the inner material of the nucleus becomes permanently bulged, distended, or extruded out of its normal, internal annular confines.
  • the mass of a herniated or "slipped" nucleus tissue can compress a spinal nerve, resulting in leg pain, loss of muscle strength and control, and even paralysis.
  • the nucleus loses its water binding ability and deflates with subsequent loss in disc height. Subsequently, the volume of the nucleus decreases, causing the annulus to buckle in areas where the laminated plies are loosely bonded.
  • Discectomy can provide good short-term results.
  • a discectomy is typically not desirable from a long-term biomechanical point of view.
  • the disc space will narrow and may lose much of its normal stability.
  • the disc height loss may cause osteo-arthritis changes in the facet joints and/or compression of nerve roots over time.
  • the normal flexibility of the joint is lost, creating higher stresses in adjacent discs. At times, it may be necessary to restore normal disc height after the damaged disc has collapsed.
  • Fusion is a treatment by which two vertebral bodies are fixed to each other by a scaffold.
  • the scaffold may be a rigid piece of metal, often including screws and plates, or allo or auto grafts.
  • Current treatment is to maintain disc space by placement of rigid metal devices and bone chips that fuse two vertebral bodies.
  • the devices are similar to mending plates with screws to fix one vertebral body to another one.
  • hollow metal cylinders filled with bone chips can be placed in the intervertebral space to fuse the vertebral bodies together (e.g., LT- CageTM from Sofamor-Danek or Lumbar I/F CAGETM from DePuy).
  • TDR devices have attempted to allow for motion between the vertebral bodies through articulating implants that allow some relative slippage between parts (e.g., ProDisc®, ChariteTM). See, e.g., U.S. Patent Nos. 5,314,477, 4,759,766, 5,401,269 and 5,556,431.
  • a flexible solid elastomeric spinal disc implant that is configured to simulate natural disc action (i.e., can provide shock absorption and elastic tensile and compressive deformation) is described in U.S. Patent Application Publication No. 2005/0055099 to Ku, the contents of which are hereby incorporated by reference as if recited in full herein.
  • Embodiments of the present invention are directed to providing patient-specific implants that can be custom configured to fit a target space or structure in a patient and/or formed based on patient image data and input from a clinician to customize treatment and/or provide ease of implantation in the patient.
  • Embodiments of the invention are directed to methods for generating custom arthoplasty implants, including spinal implants.
  • the methods include: (a) programmatically analyzing a patient's image data to electronically obtain shapes and dimensions of relevant anatomical features of a target region of the patient; and (b) fabricating a patient-specific replacement implant for the patient using the analyzed patient image data.
  • the implant can be a spinal implant, such as a total disc replacement (TDR), a nucleus, a facet joint or an inter-process spacer and the like.
  • TDR total disc replacement
  • the method can further include, before the fabricating step, electronically generating a 3-D model of at least one level of a target disc space of each patient using respective patient image data, then generating a 3-D model of the total disc replacement spinal implant based on data from the 3-D model of the target disc space.
  • the programmatically analyzing step can include generating an electronic graphic 3-D anatomical model of at least one target spinal location undergoing treatment; and electronically constructing the patient- specific replacement spinal implant based on the generated model.
  • the patient-specific spinal implant is an intervertebral disc implant
  • the programmatically analyzing step includes: (a) generating an electronic graphic anatomical model of at least one target region or space (such as, for example, an intervertebral disc space) undergoing treatment; (b) electronically constructing a replacement implant model based on the target space model; and (c) electronically correcting the constructed model according to the patient's pathology and/or anatomy to shape and/or size the patient-specific replacement implant.
  • the implant comprises a TDR implant and the methods can include: electronically determining 3-D surface contours of vertebral endplates at the at least one target disc level to be treated using the patient image data; and generating an electronic 3-D model of the total disc replacement implant that includes the 3-D surface contours that substantially corresponds to the determined 3- D contours.
  • inventions are directed to systems for producing custom implants.
  • the systems include a processor system configured to generate a 3-D graphic model of a patient-specific implant using dimensions and features of a target region of a respective patient obtained from patient medical image data.
  • the systems can include at least one clinician workstation in communication with the processor system.
  • the workstation can include a display configured to display the 3-D model of the implant (which may be, for example, a spinal implant).
  • the systems may also include: a 3-D model construct circuit in communication with the workstation configured to generate the 3- D model of the patient-specific implant and to generate a 3-D model of a target actual space in respective patients.
  • the systems may also include a patient image data server in communication with the 3-D model construct circuit.
  • Still other embodiments are directed to methods for generating custom spinal implants that include: (a) programmatically generating an electronic graphic anatomical model of at least one target intervertebral disc space undergoing treatment using electronic patient image data to define shapes and dimensions of relevant anatomical features of a spine of the patient; (b) electronically constructing a replacement implant model based on the anatomical disc space model; and (c) electronically correcting the constructed model according to the patient's pathology and/or anatomy to shape and/or size the patient-specific total disc replacement implant.
  • the implants can include an arthoplastic implant, such as, for example, a total disc replacement (TDR) spinal implant comprising superior and inferior surfaces customized to match local bone structure in a respective patient.
  • TDR total disc replacement
  • the TDR or other arthoplastic implant may optionally include a flexible molded elastomeric implant having a predetermined patient-specific shape and dimensions.
  • Some embodiments are directed to at least one medical arthoplasty implant in a sterile package, the implant in the package comprising a body with a shape and dimensions customized to match local bone structure in a target joint space of a respective patient.
  • Some embodiments are directed to computer program products for providing physician interactive access to patient medical volume data for constructing spinal implants using a computer network.
  • the computer program product includes a computer readable storage medium having computer readable program code embodied in the medium.
  • the computer-readable program code includes: (a) computer readable program code configured to generate patient-specific graphic 3-D spinal implant models using data from medical images of a target region of a patient; and (b) computer readable program code configured to interactively accept user input to adjust features, sizes and/or dimensions of the patient-specific spinal implant models.
  • a display can display a virtual image of an implant shape that can be placed in the target space and altered in different shapes and dimensions to allow a clinician to virtually visualize the implant's affect post-surgery.
  • Figure IA is a schematic illustration of a system configured to provide data used to generate patient-specific implants according to embodiments of the present invention.
  • Figure IB is a schematic illustration of a system configured to provide data used to generate patient-specific implants according to embodiments of the present invention.
  • Figure 2 is a schematic illustration of a serial sequence of steps that can be used to generate patient-specific spinal implants according to embodiments of the present invention.
  • Figure 3 is a flow chart of operations that can be used to carry out embodiments of the present invention.
  • Figure 4 is a flow chart of other operations that can be used to carry out embodiments of the present invention.
  • Figure 5A is a 2-D screen shot of a patient image of a spinal disc space targeted for treatment.
  • Figure 5B is an electronic model of a natural spinal disc constructed to have substantially the same dimensions and shape as the spinal disc in the image of Figure 5A.
  • Figure 5C is an electronic model of spinal implant adjusted to correct a scoliotic angle relative to the natural disc model shown in Figure 5B according to embodiments of the present invention.
  • Figure 6A is a 2-D screen shot of a patient image of a spinal disc space targeted for treatment.
  • Figure 6B is an electronic model of a natural spinal disc constructed to have substantially the same dimensions and shape as the spinal disc in the image of Figure 6A.
  • Figure 6C is an electronic model of spinal implant adjusted in thickness and wedge angle relative to the natural disc model shown in Figure 6B to reduce spondylolisthesis according to embodiments of the present invention.
  • Figure 7 is a block diagram of a data processing system according to embodiments of the present invention.
  • Figure 8 is a schematic illustration of an interactive workstation configured to generate a model of a spinal implant and allow electronic alteration of features of the spinal implant according to embodiments of the present invention. .
  • Figure 9 is a schematic illustration of a workstation configured to simulate a patient's lumbar spine and illustrate projected therapeutic effect on spinal configuration/posture using an electronic model of a spinal implant.
  • Figure 10 is a top perspective view of a custom TDR implant according to some embodiments of the present invention.
  • Figures 11A-11D are schematic illustrations of exemplary operations that can be used to mold patient-specific spinal implants according to embodiments of the present invention.
  • Figures 12A-12C are schematic illustrations of exemplary operations that can be used to mold patient specific implants according to embodiments of the present invention.
  • Figure 13 is a side view of an exemplary custom spinous process cuff according to some embodiments of the present invention.
  • Figure 14 is a side view of a spine illustrating a custom wide range facet prosthesis according to some embodiments of the present invention.
  • phrases such as “between X and Y” and “between about X and Y” should be interpreted to include X and Y.
  • phrases such as “between about X and Y” mean “between about X and about Y.”
  • phrases such as “from about X to Y” mean “from about X to about Y.”
  • embodiments of the invention may be embodied as a method, system, data processing system, or computer program product. Accordingly, the present invention may take the form of an entirely software embodiment or an embodiment combining software and hardware aspects, all generally referred to herein as a "circuit" or "module.” Furthermore, the present invention may take the form of a computer program product on a computer-usable storage medium having computer-usable program code embodied in the medium. Any suitable computer readable medium may be utilized including hard disks, CD-ROMs, optical storage devices, a transmission media such as those supporting the Internet or an intranet, or magnetic or other electronic storage devices.
  • the term "automatic” means that substantially all or all of the operations so described can be carried out without requiring the assistance and/or manual input of a human operator.
  • electronic means that the system, operation or device can be carried out using any suitable electronic media and typically includes programmatically controlling communication between a server in communication with a patient image database and workstations using a computer network.
  • hub means a node and/or control site (or sites) that controls data exchange using a computer network.
  • spinal disc implant and spinal disc prosthesis are used interchangeably herein to designate total disc replacements using an implantable total disc replacement (TDR) prosthesis (rather than a nucleus only) and as such are configured to replace the natural spinal disc of a mammalian subject (for veterinary or medical (human) applications).
  • TDR implantable total disc replacement
  • spinal implant includes TDR spinal disc implants and alternative spinal implants, such as, for example, spinal annulus implants, spinal nucleus implants, facet (facet joint replacement) implants, posterior dynamic stabilization implants (such as interprocess spacers), and spinous process implants as well as implants for other portions of the spine.
  • match means to take on a shape that corresponds to target local (bone) structure interfaces.
  • the superior and/or inferior surfaces can be fabricated to have local depressions and rises that mimic that of the excisable natural bone in a manner that engages and accepts the irregularities of adjacent local bone to provide a more natural stable position and/or that can provide increased contact area between the implant and adjacent bone structure t to improve load distribution and increase durability of the device and the bone over standardized surfaces of conventional devices.
  • keel means an implant component, feature or member that is configured to be received in a recess or mortise in an adjacent bone to facilitate short and/or long-term fixation and/or to provide twist or torsion resistance in situ.
  • the term “flexible” used with respect to the keel means that the member could be flexed or bent.
  • the implant can include a keel, which may be flexible but has sufficient rigidity to be substantially self-supporting so as to be able to substantially maintain a desired configuration outside of the body. If flexible, the keel can include reinforcement to increase its rigidity.
  • the term "flexible” with respect to a total disc replacement implant means that the implant is resilient as will be discussed further below. See, e.g., U.S. Patent Application Publication No. 2005/0055099 to Ku, the contents of which are hereby incorporated herein by reference thereto.
  • the term “mesh” means any flexible material in any form including, for example, knotted, braided, extruded, stamped, knitted, woven or otherwise, and may include a material with a substantially regular foramination pattern and/or irregular foramination patterns.
  • macropores refers to apertures having at least about a 1 mm diameter or width size, typically a diameter or width that is between about 1 mm to about 3 mm, and more typically a diameter or width that is between about 1 mm to about 1. 5 mm (the width dimension referring to non-circular apertures).
  • the macropores may promote bony through-growth for increased fixation and/or stabilization over time.
  • the present invention may be embodied as devices, systems, methods, and/or computer program products. Accordingly, the present invention may be embodied in hardware and/or in software (including firmware, resident software, micro-code, etc.). Furthermore, the present invention may take the form of a computer program product on a computer-usable or computer-readable storage medium having computer-usable or computer-readable program code embodied in the medium for use by or in connection with an instruction execution system.
  • a computer-usable or computer-readable medium may be any medium that can contain, store, communicate, propagate, or transport the program for use by or in connection with the instruction execution system, apparatus, or device.
  • the computer-usable or computer-readable medium may be, for example but not limited to, an electronic, magnetic, optical, electromagnetic, infrared, or semiconductor system, apparatus, device, or propagation medium. More specific examples (a non-exhaustive list) of the computer-readable medium would include the following: an electrical connection having one or more wires, a portable computer diskette, a random access memory (RAM), a read-only memory (ROM), an erasable programmable read-only memory (EPROM or Flash memory), an optical fiber, and a portable compact disc read-only memory (CD-ROM).
  • RAM random access memory
  • ROM read-only memory
  • EPROM or Flash memory erasable programmable read-only memory
  • CD-ROM portable compact disc read-only memory
  • the computer-usable or computer-readable medium could even be paper or another suitable medium, upon which the program is printed, as the program can be electronically captured, via, for instance, optical scanning of the paper or other medium, then compiled, interpreted, or otherwise processed in a suitable manner, if necessary, and then stored in a computer memory.
  • Computer program code for carrying out operations of the present invention may be written in an object oriented programming language such as Java, Smalltalk or C++.
  • object oriented programming language such as Java, Smalltalk or C++.
  • the computer program code for carrying out operations of the present invention may also be written in conventional procedural programming languages, such as the "C" programming language or in a visually oriented programming environment, such as VisualBasic.
  • Certain of the program code may execute entirely on one or more of the user's computer, partly on the user's computer, as a stand-alone software package, partly on the user's computer and partly on a remote computer or entirely on the remote computer.
  • the remote computer may be connected to the user's computer through a local area network (LAN) or a wide area network (WAN), or the connection may be made to an external computer (for example, through the Internet using an Internet Service Provider).
  • LAN local area network
  • WAN wide area network
  • Internet Service Provider for example, AT&T, MCI, Sprint, EarthLink, etc.
  • some program code executes on a workstation "client” computer and some program code executes on a hub server (such as a Patient Image Data Server and/or a web application or Administrative Server) with communication between the clients and the hub server using a computer network, for example, the Internet.
  • a hub server such as a Patient Image Data Server and/or a web application or Administrative Server
  • These computer program instructions may also be stored in a computer-readable memory or storage that can direct a computer or other programmable data processing apparatus to function in a particular manner, such that the instructions stored in the computer-readable memory or storage produce an article of manufacture including instruction means which implement the function/act specified in the block or blocks.
  • the computer program instructions may also be loaded onto a computer or other programmable data processing apparatus to cause a series of operational steps to be performed on the computer or other programmable apparatus to produce a computer implemented process such that the instructions which execute on the computer or other programmable apparatus provide steps for implementing the functions/acts specified in the block or blocks.
  • a system 10 for facilitating patient-specific (or custom) spinal implants is shown.
  • the system 10 can be implemented using a computer network and can include at least one processor or processor system that can be used to analyze and/or extract geometric and dimensional data from patient image data.
  • the processor can be a digital signal processor.
  • the term "computer network" includes one or more local area networks (LAN), wide area networks (WAN) and may, in certain embodiments, include a private intranet and/or the public Internet (also known as the World Wide Web or "the web").
  • the system 10 can operate on one or more computers, with a Patient Image Data Module 20 and workstations 25.
  • the workstations may be considered “clients” and the Patient Image Module 20 may reside on a Patient Image Server, such as, for example, a hub 15 that is in communication with the client workstations 25.
  • the workstations 25 typically include at least one display 25d that can be used to view images such as the 3-D model of the natural deteriorated, injured target structure and/or a 3-D model of the artificial implant.
  • the hub 15 and/or workstation(s) 25 can also be in communication with a 3-D model construct circuit 30 and, optionally, a mold configuration circuit 40.
  • the 3-D model construct circuit 30 can be configured to generate a patient-specific 3-D model of a spinal implant using patient image data.
  • the mold configuration circuit 40 can be used to define a mold body that can create a molded implant having the defined patient-specific shape.
  • At least one client workstation 25 can reside at a clinician facility, such as a clinic or medical facility or physician's office, and another may reside at a site remote from the clinician facility, such as at an implant pre-manufacturing or manufacturing site or custom-shape construct site.
  • the hub 15 can be a single server or computer and may reside at a central (administrative) site or can comprise a plurality of servers or computers that electronically communicate with hardware and/or software residing at different sites (nodes).
  • the 3-D model construct circuit 30 can reside in or be controlled by a 3-D construct interface server 30s that retrieves patient image data 21 and relays to the requesting workstation 25.
  • the patient image data 21 may reside on the server 20s or may reside in a different server or other electronic storage device and communicate with the patient image data server 20s or directly with the interface server 30s and/or circuit 30.
  • the custom or patient- specific implant will have a 3-D shape.
  • Volumetric image data that can be analyzed to obtain shapes and dimensions for the implant can be generated from known imaging modalities, such as, for example, MRI (Magnetic Resonance Imaging) and CT (Computed Tomography).
  • Known two-dimensional (2-D) and three-dimensional (3-D) visualization products provide medical images that can render images from stored electronic data files.
  • the data input used to create the image renderings can be a stack of image slices from a desired imaging modality, for example, a CT and/or MRI modality.
  • the visualization can convert the image data into an image volume to create renderings that can be displayed on a workstation display.
  • Image visualizations using the multi-dimensional image data can be carried out using any suitable system such as, for example, PACS (Picture Archiving and Communication System).
  • PACS Picture Archiving and Communication System
  • the 3-D model construct circuit 30 can be configured to construct a spinal implant shape and size based on patient image data of a target treatment region (such as a disc space) in the patient.
  • some workstations 25 may also be configured to communicate with other workstations via a portal or other interface system. That is, a first clinician may forward a request for construction of a custom spinal implant for Patient A to a second clinician (that may be an implant design or other specialist) that may be onsite or remote for a virtual "consult".
  • the system 10 can be configured to generate an initial implant shape, then allow clinician interactive input for adjusting shapes, features, and/or dimensions, as will be discussed further below.
  • the system 10 can access the patient image data and electronically generate a patient-specific implant construct model.
  • imaging information obtained in advance of a surgical procedure can be carried out to evaluate the target implant space and determine the associated shapes and dimensions for a particular patient, including, for example, width space, wedge angle, anterior height, concavity of anterior and superior surfaces, and the like.
  • This information can be used to select which of certain prefabricated implant sizes (S, M, L, XL), and which wedge angle (convexity that matches the concavity of the target disc) within that size (6, 10 or 14 degrees) as well as which anterior height (9, 1 1 or 13 mm) is desired.
  • the wedge angle and anterior heights are examples, and may be suitable for typical L4 or L5 replacements.
  • the same information can be used to select which trial size with its different convexities, and anterior heights and the like should be provided in the surgical kit (the term “trial” refers to a surgical instrument for inserting into the target space before the implant itself to stabilize and/hold the space while inserting/drilling or milling a mortise or keel way).
  • the term "trial” refers to a surgical instrument for inserting into the target space before the implant itself to stabilize and/hold the space while inserting/drilling or milling a mortise or keel way).
  • embodiments of the invention can directly provide the implants that matches patient physiology (patient matched implant or PMI) and reduces the time and labor associated with onsite selection of tools and implants on the day of surgery or during a surgical procedure and can provide a better fit for the respective patient.
  • the patient-custom device can also have a custom formulation (e.g., stiffness, hardness, mobility, flexibility, compression or tensile strength and/or torsional strength), and/or also a custom variable formulation (softer or more compliant in some given regions relative to others) in order to better comply with the bone density/strength of the patient at the interface with the device.
  • a custom formulation e.g., stiffness, hardness, mobility, flexibility, compression or tensile strength and/or torsional strength
  • a custom variable formulation softer or more compliant in some given regions relative to others
  • Patients with a local bone defect and/or osteolysis may also benefit from a locally softer device (at the interface where the bone is weak) with increased hardness where the bone is stronger and can take a - greater load.
  • the patient-device can also be configured to allow for increased mobility in one direction relative to another, typically considering the status of local surrounding tissues and/or bone loading.
  • the custom device can be configured with custom position, size and shapes and the relative position of contacting elements (by its geometry), and can be designed to provide selectability of the formulation and mechanical properties of the material. This adjustability can allow significant therapeutic indications of such device.
  • a clinician when a clinician finalizes or approves of a customized spinal implant configuration for a particular patient at a first location 25c (such as a medical facility), he/she can forward an electronic order or requisition with the specific implant shape or electronic data sufficient to generate the implant shape as defined by an electronic 3-D model of the implant to a workstation 25m associated with a manufacturing system, using HIPAA compliant data sharing.
  • HIPAA refers to the United States laws defined by the Health Insurance Portability and Accountability Act.
  • the requisition can be carried out electronically to schedule production in a "just in time" inventory system and can be made without using patient identifiable data, but using a system that correlates the specific implant shape to a patient and identifies the need date, and shipping information.
  • FIG. 2 illustrates an exemplary sequence of actions that can be carried out to generate a patient-specific custom implant.
  • a total disc replacement (TDR) is contemplated for this patient.
  • TDR total disc replacement
  • patient image data of at least the level of the lumbar spine with the affected disc space is electronically analyzed to generate a 3-D model of the target disc space.
  • the 3-D model of the natural disc is generated using dimensions and geometric shapes of the natural disc and disc space based on the patient image data.
  • An intervertebral (IVD) implant can be generated based on the model of the natural disc as shown in Figure 2 at screen 55.
  • a patient-specific mold can be created by a CAD software system in response to the patient-specific IVD implant shape.
  • the IVD implant 75 can be molded using the defined mold shape.
  • the implants can be custom fabricated using other manufacturing processes to yield implants with a geometry, features and/or size that is based on actual patient image data that defines each patient's specific anatomical space, injured target excisable bone structure and/or therapeutic goals.
  • portions of an implant can be molded rather than the entire primary implant body.
  • the spinal implant can be a nucleus or annulus implant, rather than a TDR implant or other spinal implants, such as a spinal facet joint replacements and spinous process inter-spacers or surface coverings for dynamic stabilization.
  • Additional features can be added to the implant after molding for fixation or attachment in situ in the body.
  • keels suture anchors, bone anchors, mesh or other bone attachment material, and the like.
  • the disc replacement can be manufactured to the shape of the patient's treated intervertebral disc (IVD), specifically in term of cross section geometry and area, and 3-D surfaces (concavity) defined by the superior and inferior adjacent vertebral endplates, while restoring an appropriate height and wedge angle for the treated disc space(s).
  • the appropriate thickness and wedge angle may be defined by analyzing the dimensions and geometry of the healthy levels of the patient's lumbar spine and by incorporating this data into predefined algorithms in order to restore an appropriate curve of the spinal lordosis or respond to other specific needs (see Figures 6C and 7C discussed below).
  • Figure 3 illustrates operations or actions that can be carried out to generate custom spinal implants according to embodiments of the present invention.
  • a patient's image data can be programmatically analyzed to electronically obtain shapes and dimensions of relevant anatomical features of a target region of a spine of the patient (block 200).
  • a patient-specific replacement spinal implant can be fabricated for the patient using the analyzed patient image data (block 210).
  • the spinal implant comprises at least one total disc replacement implant and the method further includes, before the fabricating step, electronically generating a 3-D model of at least one level of a target disc space of each patient using respective patient image data, then generating a 3-D model of the total disc replacement spinal implant based on data from the 3-D model of the target disc space (block 203).
  • the method can include electronically accepting user input to adjust features of the 3-D model of total replacement disc implant to define an adjusted shape different from the 3-D model of the disc space that is used for the fabricating step (block 205).
  • the user input can be by freehand (manual) drawing using a finger- contact on the screen, a stencil, light beam, or other input tool.
  • the user input can include selectable tools, such as electronically assisted line or curve shape-assisted boundary drawing features, including, for example, spline format tools.
  • Manipulation tools that allow the user to move a drawn line or inserted point, adjust the shape or size, zoom, rotate or otherwise manipulate the shape and/or features or boundary lines can be provided as a tool box or menu selection.
  • An "undo", erase or backtrack tool can be provided to allow ease of editing the initial or altered shape.
  • the programmatically analyzing step can include analyzing patient image data of superior and inferior vertebral endplates associated vyith the at least one target disc space (block 206).
  • the fabricating step can include molding an intervertebral disc spinal implant shape with a patient- specific shape having superior and inferior surfaces defined to substantially match the analyzed superior and inferior vertebral endplates (block 208).
  • some embodiments of the present invention can provide 3-D surfaces that substantially, if not exactly, match the irregularities of the bone. Therefore, the contact area between the implant and the local bone structures can be optimized (increased) and the load distribution improved for increased durability of the implant as well as the bone. Also, having matching surfaces at the interfaces with the bone may provide the implant with a more natural / stable position, compared to a similar device with non-matching / standard surfaces. The fixation of the device in situ may also be improved.
  • Figure 4 illustrates exemplary operations that can be carried out according to some embodiments of the present invention.
  • a virtual representation of the 3-D model of the replacement disc implant can be electronically displayed in an electronic anatomical graphic model of a spinal column of the patient (block 220).
  • the method can then electronically graphically simulate a post-surgical affect, on posture, height and/or wedge angle on the patient's spinal column using the virtual representation of the generated disc (block 225).
  • the simulating can include accepting user input to allow a clinician to modify a lateral wedge angle and/or thickness or other selected features for therapeutic effect (block 223).
  • - geometry - ⁇ and features of the implant may be changed or adjusted according to the needs of the patient and/or according to the needs of the physician in order to customize the treatment and/or improve the ease of implantation of the device.
  • the implant device could be changed to match a specific approach, be usable with various additional means of fixation and also relocate the attachment points, if applicable.
  • embodiments of the invention may find applications for patients with degenerative disc diseases, as well as for patients with scoliosis, on one or several levels.
  • an implant could be made with a lateral wedge angle to comply with a scoliotic level or potentially compensate for lateral inclination of the disc space.
  • An exemplary custom construct process cycle may include:
  • data taken from the medical images is used to generate a 3D model of the bone structures of the considered level(s).
  • Conventional software such as MIMICS from Materialise, (having a place of business in Ann Arbor, MI) can be used to form the 3D spinal implant model: -
  • the geometry of a target degenerated disc space can be obtained by a relatively simple subtraction of 3D parts.
  • an approximate or rough 3D shape can be electronically generated that covers the target disc space.
  • the volume of the vertebral bodies can be subtracted from this shape to obtain the 3D implant model that has the volume and geometry of the disc space, with the 3D surfaces of the endplates.
  • the implant geometry can be done using MIMICS or another CAD software, such as SolidWorks, from SolidWorks, Corporation, Concord, Massachusetts.
  • the 3D model of the degenerated disc space can then be exported in the desired CAD module.
  • the geometry/geometric features of the implant model of the degenerated disc space can be changed or adjusted as desired or needed. This can be done with a trained operator using CAD software.
  • embodiments of the invention can provide modules or software that can apply standard changes (thickness, wedge angles, diameter, contour, attachment features, partition of the artificial disc for composite TDR, and the like) that could be used directly by physicians and be accessible on a workstation 25 ( Figure IA).
  • Some embodiments of the invention can accept clinician input such as "Add 2 mm of thickness to the disc” as a physician request that is clearly defined and that can.be processed to change the 3D model of the custom disc.
  • clinician input such as "Add 2 mm of thickness to the disc”
  • the systems of the present invention can answer this request by iteratively changing predefined parameters (dimensions / specific features of the disc — a simple example for this case could be to create a recess in the designated area or have a softer material in contact with it) and simulate the custom disc through a custom finite element model of the patient's treated functional spine unit.
  • the finite element model can be built from the 3D model of the bone structures that would be meshed and exported into FEM software such as ABAQUS or ANSYS.
  • the system can be configured to define suitable material properties, interfaces, simulation of surrounding tissues, and different types of physiological simulations based on different implant and patient configurations. Additional data can be used to allow adjustments, even very subtle adjustments on the implant geometry and material properties, which can also be customized. These types of adjustments may improve the range of indications and success rate of TDRs and many other devices.
  • the model can be used to produce the components (such as molds) that will be used for the manufacturing of the custom part (see Figures 1 IA-I ID, 12 A- 12C).
  • the custom implant 75 can be a three- dimensional TDR spinal disc implant structure that provides a desired anatomical shape, shock absorbency and mechanical support.
  • the anatomical shape can have an irregular solid volume to fill a target intervertebral disc space.
  • the coordinates of the implant body can be described using the anatomic directions of superior (toward the head), inferior (toward the feet), lateral (away from the midline), medial (toward the midline), posterior (toward the back), and anterior (toward the front). From a superior view, the implanted device has a kidney shape with the hilum toward the posterior direction. The margins of the device in sagittal section are generally contained within the vertebral column dimensions.
  • the term "primary surface” refers to one of the superior or inferior (endplate) surfaces.
  • the size of the prosthetic spinal disc 75 will typically vary for different individuals. A typical "average" size of an adult lumbar .disc is 3-5 cm in the minor axis, 5 cm in the major axis, and 1.5 cm in thickness, but each of these dimensions can vary.
  • Figures 5A-5C and 6A-6C illustrate in 2-D an exemplary construct process as described above.
  • image data of the patient's spine 175 can be electronically obtained and analyzed and the shape of the vertebral endplates can be identified.
  • Figures 5B and 6B show that in a second step, a 3-D model of the disc space (generically referred to by designation 75m) can be created.
  • Figures 5C and 6C illustrate that a first disc model 75mj can be adjusted or corrected according the patient's pathology to provide the custom implant shape 75ni2.
  • the corrected model 75m2 can define the shape of the custom designed total disc replacement.
  • Figures 5A-SC illustrate a custom disc corrected for scoliotic angle
  • Figures 6A-6C illustrate a custom disc corrected for reduction of spondylolisthesis and increase of thickness and wedge angle.
  • a data processing system 116 that may be used to implement the custom system described herein and/or shown in the figures, in accordance with some embodiments of the present invention, comprises input device(s) 25 ( Figure IA) which can include a keyboard or keypad, a display 25d ( Figure IA), and a memory 136 that communicate with a processor 100.
  • the data processing system 116 may further include an input/output (I/O) circuits and/or data port(s) 146 that also communicate with the processor 100.
  • the system 116 may include removable and/or fixed media, such as floppy disks, ZIP drives, hard disks, or the like, as well as virtual storage, such as a RAMDISK.
  • the I/O data port(s) 146 may be used to transfer information between the data processing system 116 and another computer system or a network (e.g., the Internet). These components may be conventional components, such as those used in many conventional computing devices, and their functionality, with respect to conventional operations, and is generally known to those skilled in the art.
  • the processor 100 may be, for example, a commercially available or custom microprocessor.
  • the memory 136 is representative of the one or more memory devices containing the software and data used for providing a calendar based time limited passcode system with interface on a display in accordance with some embodiments of the present invention.
  • the memory 136 may include, but is not limited to, the following types of devices: cache, ROM, PROM, EPROM, EEPROM, flash, SRAM, and DRAM.
  • the memory 136 may contain up to two or more categories of software and/or data: an operating system 152, I/O Device Drivers 158, data 156 such as Patient Image Data 126, and application programs 154.
  • the operating system 152 may be any operating system suitable for use with a data processing system, such as IBM®, OS/2®, ADC® or zOS® operating systems or Microsoft® Windows®95, Windows98, Windows2000 or WindowsXP operating systems Unix or LinuxTM.
  • IBM, OS/2, AIX and zOS are trademarks of International Business Machines Corporation in the United States, other countries, or both while Linux is a trademark of Linus Torvalds in the United States, other countries, or both.
  • Microsoft and Windows are trademarks of Microsoft Corporation in the United States, other countries, or both.
  • the input/output device drivers 158 typically include software routines accessed through the operating system 152 by the application programs 154 to communicate with devices such as the input/output circuits 146 and certain memory 136 components.
  • the application programs 154 are illustrative of the programs that implement the various features of the circuits and modules according to some embodiments of the present invention.
  • the data 156 represents the static and dynamic data used by the application programs 154 the operating system 152 the input/output device drivers 158 and other software programs that may reside in the memory 136.
  • application programs 154 may include a Patient-Specific 3-D Implant Construct Module 120 and may optionally include a 3-D Patient Spinal Image Module 124 that can simulate a post-surgical spinal configuration interactively using custom implants electronically inserted in the spine.
  • the application program 154 may be located in a local server (or processor) and/or database or a remote server (or processor) and/or database, or combinations of local and remote databases and/or servers.
  • Figure 7 illustrates exemplary hardware/software architectures that may be used in systems such as shown in Figures 1 A-IB, 2-4, and 8-9, it will be understood that the present invention is not limited to such a configuration but is intended to encompass any configuration capable of carrying out operations described herein. Moreover, the functionality of the data processing systems and the hardware/software architectures may be implemented as a single -- processor system, a multi-processor system, or even a network of stand-alone computer systems, in accordance with various embodiments of the present invention.
  • Computer program code for carrying out operations of data processing systems discussed above with respect to the figures may be written in a high-level programming language, such as Java, C, and/or C++, for development convenience.
  • computer program code for carrying out operations of embodiments of the present invention may also be written in other programming languages, such as, but not limited to, interpreted languages.
  • Some modules or routines may be written in assembly language or even micro-code to enhance performance and/or memory usage. It will be further appreciated that the functionality of any or all of the program modules may also be implemented using discrete hardware components, one or more application specific integrated circuits (ASICs), or a programmed digital signal processor or microcontroller.
  • ASICs application specific integrated circuits
  • FIG 8 is a schematic illustration of an interactive display 25d.
  • a clinician can select computer-assisted tools 176 that can be electronically placed or overlayed onto the patient image 175 to select the target region of interest for implant construct, excision review (and relevant endplates).
  • a first model 75m ⁇ can be electronically constructed.
  • a clinician can rotate, turn or otherwise turn the disc to illustrate views of the 3-D disc model 75mi.
  • the interactive display 25d can also allow .the clinician to alter the shape of one or more features of the disc 75mi to generate an adjusted model 75m 2 .
  • Figure 9 illustrates a simulated projected postsurgical patient spine configuration using the patient image data and either disc model 75mi or 75ni 2 .
  • the system can be configured to suggest implant configurations based on measurements of the patient data and a desired treatment outcome.
  • the simulated spine (entire vertebral column or subsets of the spine) can be generated using patient image data projected onto or based on known commercially available 3-D interactive human anatomy software for medical and heath professionals, such as, for example, Interactive Spine, by Hilali Noordeen et al.
  • Figures 11 A-I ID illustrate exemplary operations that can be used to mold patient-specific implants.
  • the 3D model 75m of the patient's target treatment region/space is obtained.
  • a substantially rigid "master" mold 77 can be fabricated based on data from the 3D model.
  • the master mold may comprise a metallic, typically stainless steel body that may be machined.
  • the master mold can be elastomeric (and may be 3D printed).
  • the shape of the master mold is substantially the same as the 3D model 75m but dimensions of the master mold 77 may be smaller/reduced compared to the end replacement implant body to compensate for the increase in volume of the part during processing.
  • the volume of the implant can increase before implantation due to hydration of the hydrogel, in order to have final dimensions that meet the 3-D implant shape requirements:
  • an insert/mold 177 is formed about the master and produced using the master 77. Silicone may be used to form the mold 177. Silicone may be a suitable economical material for a disposable mold. As , shown in Figure HC, the mold 77 has a cavity 177c that has the shape of the master 77 used to shape the implant to be manufactured. The mold 177 can then be used to produce the implant 75 ( Figure HD).
  • the molding process can be any suitable process, such as for example, an injection molding process, as well as processes described in co-ending U.S. Provisional Application Serial No. 60/761,903, the contents of which are hereby incorporated by reference as if recited in full herein.
  • a a silicone or other elastomeric insert can be placed into a metallic frame to define the cavity shape and size instead of having the cavity defined by the metallic frame itself.
  • the flexibility of an elastomeric mold,. such as for example, silicone can allow for some variation of the mold cavity during heating and cooling periods (if applicable).
  • the implant 75 can be placed in a sterile package 75 and otherwise processed (trimmed (if applicable), thermally cycled, hydrated, packaged, sterilized (one or more of the operations can be carried out before packaging) and finalized for use.
  • Figures 12A-12C illustrate another methodology that can be used to form the custom implant. As shown in Figure 12A, similar to Figure HA, the 3-D model 75m can be obtained.
  • a rigid mold 178 comprising a plurality of attachable members 178i, 178 2 , 1783, 178 4 can be fabricated, such as machined, based on data from the 3D model 75m with inner surfaces shaped (3D surfacing) in order to create, when assembled, a cavity 178c with the shape of the implant 75 to be produced.
  • the mold body typically includes two or more attachable members although shown with four discrete members that are held together with frame members 179i, 179 2 -" Pins, screws, clamps or other mechanisms can be used to hold the mold members 178j, 1782, 1783, 178 4 snugly together during the molding process.
  • the mold cavity 178c is adjusted to have a different size from that of the 3-D model 75m (smaller) so that the implant 75 will have the required dimensions after swelling through processing, such as, for hydrogels, a hydration process.
  • the mold 178 can be used to produce the implant 75.
  • the molding can be carried out using an injection molding process as well as the process described in the above-referenced provisional application.
  • the molding system can be configured to allow for variation of the volume of the mold cavity 178c during heating and cooling periods, such as holding the members together using a spring system or a hydraulic/pneumatic control of the pressure inside the mold cavity 178c through relative controlled displacement of the different mold components 178i, 1782, 1783, 1784.
  • the implant can be placed in a sterile package 75p.
  • the implant can be processed to meet size and functional requirements before or after packaging (i.e., trimmed (if applicable), thermally cycled, hydrated, packaged, sterilized) and finalized.
  • each block represents a module, segment, or portion of code, which comprises one or - more executable instructions for implementing the specified logical function(s).
  • the functions) noted in the blocks might occur out of the order noted. For example, two blocks shown in succession may, in fact, be executed substantially concurrently or the blocks may sometimes be executed in the reverse order, depending on the functionality involved.
  • the implant 75 can be configured as a flexible elastomeric MRI and CT compatible (i.e., compatible for use in CT and MRI imaging apparatus) spinal intervertebral disc implant.
  • the implant 75 can have a solid elastomeric body with mechanical compressive and/or tensile elasticity that is typically less than about 100 MPa (and typically greater than 1 MPa), with an ultimate strength in tension generally greater than about 100 kPa, that can exhibit the flexibility to allow at least 2 degrees of rotation between the top and bottom faces with torsions greater than 0.01 N-m without failing.
  • the implant 75 can be configured to withstand a compressive load greater than about 1 MPa.
  • the implant 75 can include bone attachment material that is typically between about 0.25 mm to about 20 mm thick, and is more typically between about 0.5 mm to about 5 mm thick.
  • the mesh comprises a DACRON mesh of about 0.7 mm thick available as Fablok Mills Mesh #9464 from Fablok Mills, Inc., located in Murray Hill, NJ.
  • the mesh may comprise cryogel material to increase rigidity.
  • the implant 75 can be made from any suitable elastomer capable of providing the desired shape, elasticity, biocompatibility, and strength parameters.
  • the implant 75 can be configured with a single, uniform average durometer material and/or may have non-linear elasticity (i.e., it is not constant).
  • the implant 75 may optionally be configured with a plurality of durometers, such as a dual durometer implant.
  • the implant 75 can be configured to be stiffer in the middle, or stiffer on the outside perimeter.
  • the implant 75 can be configured to have a continuous stiffness change, instead of two distinct durometers.
  • a lower durometer corresponds to a lower stiffness than the higher durometer area. For example, one region may have a compressive modulus that is between about 11-100 MPa, while the other region may have a compressive modulus that is between 1-10 MPa.
  • the implant 75 can have a tangent modulus of elasticity that is about 1-10 MPa, typically about 3-5 MPa, and water content of between about 30- 60%, typically about 50%.
  • Some embodiments of the implantable spinal disc 75 can comprise polyurethane, silicone, hydrogels, collagens, hyalurons, proteins and other synthetic polymers that are configured to have a desired range of elastomeric mechanical properties, such as a suitable compressive elastic stiffness and/or elastic modulus.
  • Elastomers useful in the practice of the invention include polyvinyl alcohol (PVA) hydrogels, polyvinyl pyrrolidone, poly HEMA, HYP ANTM and Salubria ® biomaterial. Methods for preparation of these polymers and copolymers are well known to the art. Examples of known processes for fabricating elastomeric cryogel material is described in Patent Nos.
  • Polymers such as silicone and polyurethane are generally known to ⁇ have (compressive strength) elastic modulus values of less than 100 MPa. Hydrogels and collagens can also be made with compressive elasticity values less than 20 MPa and greater than 1.0 MPa. Silicone, polyurethane and some cryogels typically have an ultimate tensile strength greater than about 100 or 200 kiloPascals. Materials of this type can typically withstand torsions greater than 0.01 N-m without failing.
  • the spinal disc body 75 may have a circumferential surface 74, a superior surface 72, and an inferior surface 73.
  • the superior and inferior surfaces 72, 73, respectively, may be substantially convex, and • may be configured with the same surface configuration of the natural disc, to mate with concave vertebral bones adjacent thereto.
  • One or more of the surfaces may also be substantially planar or concave.
  • the circumferential surface 74 of spinal disc body 75 corresponds to the annulus fibrosis ("annulus") of the natural disc and can be described as the annulus surface 74.
  • the superior surface 72 and the inferior surface 73 of spinal disc body 75 correspond to vertebral end plates ("end plates") in the natural disc.
  • the medial interior of spinal disc body 75 corresponds to the nucleus pulposus ("nucleus") of the natural disc.
  • the implant 75 can include a porous covering, typically a mesh material layer, on each of the superior and inferior primary surfaces 72, 73, respectively, and may also include a porous, typically mesh, material layer on the annulus surface 74 (not shown). Bone attachment members can engage the mesh material at defined locations 71 noted by the "cross" in Figure 10.
  • the implant 75 can include flex or rigid keels 69 on the superior and inferior surfaces as shown.
  • the implant 75 may be configured to allow vertical passive expansion or growth of between about 1-40% in situ as the implant 75 absorbs or intakes liquid due to the presence of body fluids.
  • the passive growth can be measured outside the body by placing an implant in saline at room temperature and pressure for 5-7 days, while held in a simulated spinal column in an intervertebrate space between two simulated vertebrates.
  • the passive expansion can vary depending, for example, on the type of covering or mesh employed and the implant material.
  • the mesh coverings along with a weight percentage of (PVA) used to form the implant body are configured to have between about 1-5% expansion in situ.
  • the mesh may comprise a biocompatible coating or additional material on an outer and/or inner surface that can increase the stiffness.
  • the stiffening coating or material can include PVA cryogel.
  • the implant body 75 is a substantially solid crystalline PVA hydrogel having a unitary body shaped to substantially correspond to a natural spinal disc of the patient.
  • An exemplary hydrogel suitable for forming a spinal implant is (highly) hydrolyzed crystalline poly (vinyl alcohol) (PVA).
  • PVA cryogels may be prepared from commercially available PVA material, typically comprising powder, crystals or pellets, by any suitable methods known to those of skill in the art. Other materials may also be used, depending, for example, on the application and desired functionality. Additional reinforcing materials or coverings, radiopaque markers, calcium salt or other materials or components can be molded on and/or into the molded body.
  • the implant can consist essentially of the molded PVA body.
  • the moldable primary implant material can be placed in a mold.
  • the moldable material comprises an irrigant and/or solvent and about 20 to 70% (by weight) PVA powder crystals.
  • the PVA powder crystals can have a MW of between about 124,000 to about 165,000, with about a 99.3-100% hydrolysis.
  • the irrigant or solvent can be a solution of about 0.9% sodium chloride.
  • the PVA crystals can be placed in the mold before the irrigant (no pre-mixing is required).
  • the mold has the desired 3-D implant body shape.
  • a lid can be used to close the mold.
  • the closed mold can be evacuated or otherwise processed to remove air bubbles from the interior cavity.
  • the irrigant can be overfilled such that, when the lid is placed on (clamped or secured to) the mold, the excess liquid is forced out thereby removing air bubbles, hi other embodiments, a vacuum can be in fluid communication with the mold cavity to lower the pressure in the chamber and remove the air bubbles.
  • the PVA crystals and irrigant can be mixed once in the mold before and/or after the lid is closed. Alternatively, the mixing can occur naturally without active mechanical action during the heating process.
  • the mold with the moldable material is heated to a temperature of between about 80 0 C to about 200 0 C for a time sufficient to form a solid molded body.
  • the temperature of the mold can be measured on an external surface.
  • the mold can be heated to at least about 80-200 0 C for at least about 5 minutes and less than about 8 hours, typically between about 10 minutes to about 4 hours.
  • the (average or max and min) temperature can be measured in several external mold locations.
  • the mold can also be placed in an oven and held in the oven for a desired time at a temperature sufficient to bring the mold and the moldable material to suitable temperatures.
  • the mold(s) can be held in an oven at about 100-200 0 C for about 2-6 hours; the higher range may be used when several molds are placed therein, but different times and temperatures may be used depending on the heat source, such as the oven, the oven temperature, the configuration of the mold, and the number of items being heated.
  • Liners can be placed in the mold to integrally attach to the molded implant body during the molding process.
  • osteoconductive material such as, for example, calcium salt can be placed on the inner or outer surfaces of the covering layers and/or the inner mold surfaces (wall, ceiling, floor) to coat and/or impregnate the mesh material to provide osteoconductive, tissue-growth promoting coatings.
  • the implant body After heating, the implant body can be cooled passively or actively and/or frozen and thawed a plurality of times until a solid crystalline implant is formed with the desired mechanical properties.
  • the molded implant body can be removed from the mold prior to the freezing and thawing or the freezing and thawing can be carried out with the implant in the mold.
  • some of the freeze and thaw steps (such as, but not limited to, between about 0-10 cycles) can be carried out while the implant is in the mold, then others (such as, but not limited- to, between about 5-20 cycles) can be carried out with the implant out of the mold.
  • the molded implant Before, during and/or after freezing and thawing (but typically after demolding), the molded implant can be placed in water or saline (or both or, in some embodiments, neither).
  • the device can be partially or completely dehydrated for implantation.
  • the resulting prosthesis can have an elastic modulus of at least about 2 MPa and a mechanical ultimate strength in tension and compression of at least 1 MPa, preferably about 10 MPa, and under about 100 MPa.
  • the prosthesis may allow for between about 1-10 degrees of rotation between the top and bottom faces with torsions of at least about 1 N-m without failing.
  • the implant can be a single solid elastomeric material that is biocompatible by cytotoxicity and sensitivity testing specified by ISO (ISO 10993-5 1999: Biological evaluation of medical devices - Part 5: Tests for in vitro cytotoxicity and ISO 10993-102002: Biological Evaluation of medical devices-Part 10: Tests for irritation and delayed-type hypersensitivity).
  • the testing parameters used to evaluate the compressive tangential modulus of a material specimen can include:
  • Fixtures fiat platens, at least 30 mm diameter
  • Figure 13 illustrates a custom spinous process implant 210 that can be fabricated to have patient-specific shapes and/or sizes and
  • Figure 14 illustrates a patient-specific synthetic wide range facet implant 310 in position in the spine.
  • the implant 310 is configured as a "spinal facet joint". This term refers to the location at which vertebral bodies meet at a rear portion of the spine. The shape of facet joints change along the length of the spine.
  • the facet joint includes bone, cartilage, synovial tissue, and menisci.
  • the implant 310 can be an elastic body that is configured to substantially conformably reside on an outer surface of the bone in a manner that allows a relatively wide range of motion between the bones forming the joint.
  • the implants 310 and 210 can be substantially "conformal" so as to have sufficient flexibility to substantially conform to a target structure's shape.
  • the facet implant or prosthesis 310 can be applied to one surface 310s (one side) of the facet joint (the bone is resurfaced by the implant) or to both surfaces of the joint, and/or may reside therebetween as a spacer to compress in response to loads introduced by the cooperating bones at the facet joint and still allow motion therebetween.
  • the spinal facet joint implant 310 can be configured to provide "wide range motion"; this phrase refers to the substantially natural motion of the bones in the facet joint which typically include all ranges of motion (torsion, lateral and vertical).
  • the implant 310 can have a thickness that is less than about 6 mm, typically between about .001- 3 mm, and may be between about .01 mm to about 0.5 mm.
  • the target structure's shape can be either the upper portion of the lower bone or the lower portion of the upper bone (one of the two vertebral bones) that meet at the rear of the spine.

Abstract

L'invention concerne des procédés et des systèmes permettant de créer des implants sur mesure par analyse programmatique des données d'images d'un patient afin d'obtenir électroniquement des formes et des dimensions des caractéristiques anatomiques pertinentes d'une zone cible du patient; et de fabriquer un implant de remplacement spécifique au patient concerné en utilisant les données d'images du patient analysées. L'invention concerne également les implants vertébraux spécifiques au patient concerné.
PCT/US2007/012517 2006-05-25 2007-05-25 Implants vertébraux spécifiques à un patient et systèmes et procédés associés WO2007139949A2 (fr)

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US60/803,141 2006-05-25

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US11576999B2 (en) 2013-10-09 2023-02-14 Lifenet Health Compressed bone composition and methods of use thereof
WO2017001851A1 (fr) * 2015-07-02 2017-01-05 Nottingham University Hospitals Nhs Trust Améliorations se rapportant à des ancrages osseux
US11013602B2 (en) 2016-07-08 2021-05-25 Mako Surgical Corp. Scaffold for alloprosthetic composite implant
RU2696924C2 (ru) * 2017-11-21 2019-08-07 Алексей Сергеевич Нехлопочин Способ переднего спондилодеза

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US20070276501A1 (en) 2007-11-29
WO2007139949A3 (fr) 2008-05-02
US8246680B2 (en) 2012-08-21

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